microsalpingoscopy RATIONALE: The more the nuclei are dye stained, the more damaged the mucosa is (Marconi 1999) A.WATRELOT CRES -LYON

Transcription

1 Fertiloscopy from diagnostic to treatment A.Watrelot CRES Centre de Recherche et d Etude de la Stérilité Lyon - France «ideal» endoscopy Mini invasive Safe Has to be able to evaluate: Tubal permeability Tubo-peritoneal environment Tubal mucosa Uterine cavity Hydropelviscopy Dye test Salpingoscopy Microsalpingoscopy hysteroscopy fertiloscopy

2 salpingoscopy A.WATRELOT CRES -LYON microsalpingoscopy RATIONALE: The more the nuclei are dye stained, the more damaged the mucosa is (Marconi 1999) fertiloscopy Should fertiloscopy replace diagnostic laparoscopy?

3 Rationale for fertiloscopy The fly study = =Fertiloscopy Laparoscop aparoscopy fertiloscopy Hydropelviscopy Dye test Salpingoscopy Microsalpingoscopy Hysteroscopy The «FLY»International study

4 Study s objectives Evaluation of the diagnostic performance of fertiloscopy, compared to diagnostic laparoscopy performances In the infertility assessment METHODOLOGY (1) Prospective multicentric study Approved protocol: CCPPRB Lyon Léon Bérard (21/12/99) Fertiloscopy first, then laparoscopy 2 surgeons A and B randomized) Video recording mandatory Control by 2 independant reviewers METHODOLOGY (2) Sensibility and specificity and diagnostic indexes Concordance study, calculation of kappa index on 6 sites RT,LT RO,LO P, Ut

5 INCLUSION CRITERIAE Age: Endoscopy scheduled for: Unexplained infertility Ovarian disorders Donor insemination failure, IUI failure- -Control after tubal surgery or suspicion of cornual blockage RESULTS (1) Files received;92 Files studied: 81 (92%) Mean age: 32 (OR: 4,8 ) Duration of infertility 4 years(or: 2,5 ) Primary infertility: 68% RESULTS (3) 100% 50% 0% Norma Endo Adhér Anom. TG F 60% 1% 6% 26% TG C 68% 1% 6% 23% 100% 50% 0% TD F 73% 0% 7% 19% TD C 74% 0% 9% 17%

6 RESULTS (4) 100% 50% 0% Norma Endo Adhér Anom. OG F 72% 11% 9% 1% OG C 79% 12% 7% 2% 100% 50% 0% Norma Endo Adhér Anom. OD F 80% 6% 5% 5% OD C 83% 5% 6% 5% RESULTS (5) 100% 50% 0% Norma Endo Adhér Anom. P F 78% 9% 9% 0% P C 77% 14% 7% 0% 100% 50% 0% Norma Endo Adhér Anom. U F 74% 0% 11% 11% U C 74% 1% 10% 12% RESULTS (7) accuracy of description of findings Sensitivity of fertiloscopy: 84% (CI 95% : 0,76-0,92) (Specificity of fertiloscopy : 68%) Sensitivity of laparoscopy : 85% (CI 95% : 0,77-0,93) (Specificity of laparoscopy : 65%)

7 RESULTS (8) Laparoscopies avoidable:75(93%) Non avoidable: 6 (7%) Discordances (8+ -) et (9- +)(=21%) -Without clinical impact: 16 cases (19,8%) -With clinical impact: 1 case (1,2%) -Consistent with the hypothesis of a discordance rate less than 1%( unilateral binomial test) RESULTATS (10) OG 0,80 OD 0,75 Study of concordance: TG 084 0,84 Crude concordance:79% TD 0,91 P Coefficient kappa: 0,75 U 0,84 CONCLUSIONS Even without salpingoscopy (not taken in account in the «FLY» study), fertiloscopy is an attractive alternative to laparoscopy Others study have shown its better costeffectiveness. The «FLY» study results: fertiloscopy should replace diagnostic laparoscopy in infertile patients with no,obvious pathology

8 Operative fertiloscopy Considerations for operative fertiloscopy Simple Reproducible At least as good as the same procedure performed db by laparoscopy+++ Procedures limited due to the coaxial operative channel Need of specific tools Operative procedures Opening of the tubes Endometriosis ADHESIOLYSIS OVARIAN DRILLING

9 Adhesiolysis and fertiloscopy Efficient for adhesions which may affect tubo-ovarian ovarian relationship Ovarian drilling 5 french Bipolar electrode in the operative channel TECHNIQUE HYDROPELVISCOPY Visualization of ovarian ligament Bilateral drilling ( holes by side) Saline solution is left in place New option= ADEPT

10 OVARIAN DRILLING PCO syndrome Ovarian drilling in: N=41 Operative time: 13 No complication RESULTS Spontaneous ovulation:29 (70,7%) Pregnancy rate (3-6 months): 13(31%)

11 Advantages of ovarian drilling Efficacy Decrease the number of miscarriages Cheap procedure Best results if practiced after failure of clomiphene citrate and before IVF Ovarian drilling and fertiloscopy Fast Easy Less risky than other surgical method ambulatory Personnal results July March cases+ 41 ovarian drilling 582 diagnostic 118 operative (16,8%) 108 followed by operative laparoscopy(15,4%) 474=«normal» (67,7%)

12 474 so-called»normal» Salpingoscopy abnormal= 38 (8,1%) Microsalpingoscopy abnormal=161 (161/474=34%) NORMAL= 313 (313/700= 44%) False route= 11 results Rectal injury=2 (0,28%) Infection =1(0,14%) Abnormal bleeding=1(0,14%) Endometriosis= 101 (14,4%) Post PID =125 (17,7 %) + infra PID=161(23%) Normal = 313 (44%) Follow-up post fertiloscopy -Surgical option 227 (32.4%) Laparoscopic 109 (15.5%) Fertiloscopic 118 ( 16.8%) Medical option (IIU,IVF) 474 (67.7%)

13 conclusions Fertiloscopy is a routine diagnostic procedure Is considered today as the gold standard in patients with no obvious pathology Has to be performed before ART Demonstrate the need of further studies on tubal assessment (microsalpingoscopy) Operative fertiloscopy becomes a reality Conclusion (1) strategy HSG Normal /doubtful pathological Fertiloscopy Normal abnormal salpingoscopy Laparoscopy Operative fertiloscopy IUI IVF microsurgery Conclusion (2) DUE TO THE SAFETY AND MINI-INVASIVENESS OF TUBO PERITONEAL EXPLORATIONS, THERE IS NO JUSTIFICATION TO PRACTICE IVF BEFORE A THOROUGH PELVIC EVALUATION